This document discusses head trauma, including: - The anatomy of the head and brain and types of injuries like concussions, contusions, hematomas. - Primary and secondary brain injuries, with primary occurring immediately from force and secondary developing over hours from hypoxia or decreased blood flow. - Assessment of head injury patients including neurological exam signs like anisocoria and posturing that indicate increased intracranial pressure. - Management focuses on airway control, preventing hypotension, limiting agitation to reduce intracranial pressure, and treating cerebral herniation syndrome aggressively.

1. Barry Kidd 2010 1
HEAD TRAUMA
What is it?
How is it caused?
What do we do in the field?

2. Barry Kidd 2010 2
HEAD TRAUMA

3. Barry Kidd 2010 3
HEAD TRAUMA
Objectives
Anatomy of head and brain
Pathophysiology of traumatic injury
Primary and secondary injury
Describe the mechanisms for the development of
secondary brain injury

4. Barry Kidd 2010 4
HEAD TRAUMA
Describe the assessment of the patient with head
injury
Describe the management of a patient with a
head injury
Identify potential problems in the management of
the patient with head injury
Recognize and describe the management of the
cerebral herniation syndrome

5. Barry Kidd 2010 5
HEAD TRAUMA
Anatomy of Head and
Brain

6. Barry Kidd 2010 6
HEAD TRAUMA
 Pathophysiology of
Traumatic Injury
Open
• Skull compromised
and brain exposed
Closed
• Skull not
compromised
and brain not
exposed

7. Barry Kidd 2010 7
HEAD TRAUMA

8. Barry Kidd 2010 8
HEAD TRAUMA
Scalp wound
• Highly vascular, bleeds briskly
 Shock: child may develop
 Shock: adult another cause
• Management
 No unstable fracture:
direct pressure, dressings
 Unstable fracture: dressings, avoid direct pressure

9. Barry Kidd 2010 9
HEAD TRAUMA

10. Barry Kidd 2010 10
HEAD TRAUMA
Skull fracture
• Linear not displaced
• Depressed
• Compound
Suspect fracture
• Large contusion or darkened swelling
Management
• Dressing, avoid excess pressure

11. Barry Kidd 2010 11
HEAD TRAUMA
 Raccoon Eyes

12. Barry Kidd 2010 12
HEAD TRAUMA
 Battle Signs

13. Barry Kidd 2010 13
HEAD TRAUMA
Penetrating
Trauma

14. Barry Kidd 2010 14
HEAD TRAUMA
Bullet
fragments

15. Barry Kidd 2010 15
HEAD TRAUMA
Concussion
• No structural injury to brain
• Level of consciousness
 Variable period of unconsciousness or confusion
 Followed by return to normal consciousness
• Retrograde short-term amnesia
 May repeat questions over and over
• Associated symptoms
 Dizziness, headache, ringing in ears, and/or nausea

16. Barry Kidd 2010 16
HEAD TRAUMA
Cerebral contusion
• Bruising of brain tissue
 Swelling may be rapid and severe
• Level of consciousness
 Prolonged unconsciousness,
profound confusion or amnesia
• Associated symptoms
 Focal neurological signs
 May have personality changes changes have
personality changes

17. Barry Kidd 2010 17
HEAD TRAUMA
Subarachnoid hemorrhage
• Blood in subarachnoid space
 Intravascular fluid “leaks” into brain
 Fluid “leak” causes more edema
• Associated symptoms
 Severe headache
 Coma
 Vomiting
 Cerebral herniation syndrome possible

18. Barry Kidd 2010 18
HEAD TRAUMA

19. Barry Kidd 2010 19
HEAD TRAUMA
Diffuse axonal injury
• Diffuse injury
• Generalized edema
 No structural lesion
 Most common injury from
severe blunt head trauma
• Associated symptoms
 Unconscious
 No focal deficits

20. Barry Kidd 2010 20
HEAD TRAUMA
Anoxic brain injury
• Small cerebral artery spasms due to anoxia
• No-reflow phenomenon
 Cannot restore perfusion of cortex
after 4–6 minutes of anoxia
 Irreversible damage occurs >4–6 minutes
• Hypothermia seems protective

21. Barry Kidd 2010 21
HEAD TRAUMA
Forces that cause skull
fracture can also cause brain
injury.

22. Barry Kidd 2010 22
HEAD TRAUMA
Primary brain injury
• Immediate damage
due to force
• Coup and contra coup
• Fixed at time of injury
Management
• Directed at prevention

23. Barry Kidd 2010 23
HEAD TRAUMA
Intracranial hemorrhage
• Epidural
 Between skull and dura
• Subdural
 Between dura and
arachnoid
• Intracerebral
 Directly into brain tissue

24. Barry Kidd 2010 24
HEAD TRAUMA
Acute epidural hematoma
• Arterial bleed
 Temporal fracture common
 Onset: minutes to hours
• Level of consciousness
 Initial loss of consciousness
 “Lucid interval” follows
• Associated symptoms
 Ipsilateral dilated fixed pupil, signs of increasing ICP,
unconsciousness, contralateral paralysis, death

25. Barry Kidd 2010 25
HEAD TRAUMA

26. Barry Kidd 2010 26
HEAD TRAUMA
Acute subdural hematoma
• Venous bleed
 Onset: hours to days
• Level of consciousness
 Fluctuations
• Associated symptoms
 Headache
 Focal neurologic signs
• High-risk
 Alcoholics, elderly, taking anticoagulants

27. Barry Kidd 2010 27
HEAD TRAUMA

28. Barry Kidd 2010 28
HEAD TRAUMA
Intracerebral hemorrhage
• Arterial or venous
 Surgery is often not helpful
• Level of consciousness
 Alterations common
• Associated symptoms
 Varies with region and degree
 Pattern similar to stroke
 Headache and vomiting

29. Barry Kidd 2010 29
HEAD TRAUMA

30. Barry Kidd 2010 30
HEAD TRAUMA

31. Barry Kidd 2010 31
HEAD TRAUMA
Secondary brain injury
• Results from hypoxia
or decreased perfusion
• Response to primary injury
• Develops over hours
Management
• Good prehospital care can help prevent

32. Barry Kidd 2010 32
HEAD TRAUMA

33. Barry Kidd 2010 33
HEAD TRAUMA
Response to injury
• Swelling of brain
 Vasodilatation with increased blood volume
 Increased ICP
• Decreased blood flow to brain
 Perfusion decreases
 Cerebral ischemia (hypoxia)

34. Barry Kidd 2010 34
HEAD TRAUMA
Decreased level of
consciousness
is an early indicator of
brain injury or rising ICP.

35. Barry Kidd 2010 35
HEAD TRAUMA
Primary and Secondary Surveys
Limit patient agitation, straining
• Contributes to elevated ICP
Airway
• Vomiting very common within first hour

36. Barry Kidd 2010 36
HEAD TRAUMA
 Nonreactive: brainstem
 Reactive: often reversible
 Both DilatedBoth dilated

37. Barry Kidd 2010 37
HEAD TRAUMA
Anisocoria

38. Barry Kidd 2010 38
HEAD TRAUMA
Eye closure
Slow: cranial nerve III
Fluttering: often hysteria

39. Barry Kidd 2010 39
HEAD TRAUMA
 Unilaterally dilated
 Reactive: ICP
increasing
 Nonreactive (altered
LOC): increased ICP
 Nonreactive (normal
LOC): not from head
injury

40. Barry Kidd 2010 40
HEAD TRAUMA
 Extremity Posturing
Decorticate
Arms flexed
and legs extended
Decerebrate
Arms extended
and legs extended

41. Barry Kidd 2010 41
HEAD TRAUMA

42. Barry Kidd 2010 42
HEAD TRAUMA
Cushing’s response
 As ICP increases, systolic BP increases
 As systolic BP increases, pulse rate
decreases

43. Barry Kidd 2010 43
HEAD TRAUMA
Hypotension
• Single instance increases mortality
 Adult (systolic <90 mmHg) 150%
 Child (systolic < age appropriate) worse

44. Barry Kidd 2010 44
HEAD TRAUMA
Hypoxia
• Perfusion decrease causes cerebral
ischemia
• Hyperventilation increases hypoxia
significantly more than it decreases ICP
Assist ventilation
• High-flow oxygen
• One breath every 6–8 seconds
• SpO2 >95%

45. Barry Kidd 2010 45
HEAD TRAUMA
Cerebral herniation syndrome
• Brain forced downward
 CSF flow obstructed, pressure on brainstem
• Level of consciousness
 Decreasing, rapid progression to coma
• Associated symptoms
 Ipsilateral pupil dilatation, out-downward
deviation
 Contralateral paralysis or decerebrate posturing
 Respiratory arrest, death

46. Barry Kidd 2010 46
HEAD TRAUMA
Cerebral herniation syndrome
• Herniation danger outweighs hypoxia
If signs resolve, stop hyperventilation.

47. Barry Kidd 2010 47
HEAD TRAUMA
Is ICP severe enough
to outweigh cerebral ischemia?

48. Barry Kidd 2010 48
HEAD TRAUMA
Summary
Knowledge of central nervous system
• Essential for assessment and management

49. Barry Kidd 2010 49
HEAD TRAUMA
Key actions
• Rapid assessment, airway management,
prevent hypotension, frequent ongoing
exams

50. Barry Kidd 2010 50
HEAD TRAUMA
Serious head injury has spinal injury
until proven otherwise
Altered mental status common

51. Barry Kidd 2010 51
HEAD TRAUMA
 Questions and Answers
 In patients with closed head injuries, a respiratory
pattern called Cheyne-Stokes breathing occurs. This
pattern is best described as:
 A. rapid breathing then shallow breathing
 B. slow shallow breathing with periods of apnea and
then deep breathing
 C. slow and shallow breathing then deep ventilation
then back to slow and shallow breathing followed by a
period of apnea
 D. rapid breathing with periods of apnea

52. Barry Kidd 2010 52
HEAD TRAUMA
 Answer
 C.

53. Barry Kidd 2010 53
HEAD TRAUMA
 The patient you are treating has suffered
a blow to the back of his head. The most
likely area of the brain affected weould be
the:
 A. occipital region
 B. parietal region
 Temporal region
 Frontal region

54. Barry Kidd 2010 54
HEAD TRAUMA
 Answer
 A.